ATI Final Exam Nursing 212 West Virginia University Institute of Technology Attempt score- 100%

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ATI Final Exam Nursing 212 West Virginia University Institute of Technology Attempt score- 100% • Before donning gloves to perform a procedure, proper hand hygiene is essential. The nurse unde... rstands that the most important aspect of hand hygiene is the amount of • A nurse is demonstrating postoperative deep breathing and coughing exercises to a client about to undergo emergency abdominal surgery for appendicitis. The nurse realizes the client may be unprepared to learn if the client • A client comes to the emergency department reporting that he has had diarrhea for 4 days and is urinating less than usual. When assessing the client’s skin turgor, the nurse should • A nurse is planning interventions for a group of clients who are obese. What can the nurse do to improve their commitment to a long term goal of weight loss? • When admitting a client, the nurse records which information in the client’s record first? • A nurse tells a client that the provider has prescribed IV fluids. The client appears to be upset about the IV catheter insertion, but says nothing to the nurse. Which of the following of the following is an appropriate nursing response? • A client who is unstable and requires frequent vital signs has an electronic blood pressure machine automatically measuring his blood pressure every 15 min. However, the machine is reading the client’s blood pressure at more frequent intervals, and the readings are not similar. The nurse checks the machine settings and observes the additional readings, but the problem continues. Which of the following is the appropriate nursing action? • A nurse is caring for a client just diagnosed with type 1 diabetes mellitus. The client is resistant to learning self injection of insulin and asks the nurse to administer all the injections. The nurse explains the importance of learning self care and appropriately adds which of the following statements? • An assistive personnel (AP) says to the nurse, "This client is incontinent of stool three or four times a day. I get angry, and I think that the client is doing it just to get attention. I think we should put adult diapers on her." Which is the appropriate nursing response? • A nurse’s neighbor is scheduled for elective surgery. The neighbor’s provider indicated that a moderate amount of blood loss is expected during the surgery, and the neighbor is anxious about acquiring an infection from a blood transfusion. Which of the following is appropriate for the nurse to suggest? • At a mobile screening clinic, a nurse is assessing a client who reports a history of a heart murmur due to aortic stenosis. To auscultate the aortic valve, the nurse should place the stethoscope at which location? • A client is admitted to the hospital with decreased circulation in the left leg. During the admission assessment, which is the most important nursing action initially? • A nurse is caring for a client who requires rectal temperature monitoring. Available at the client's bedside is a thermometer is with a long, slender tip. Which of the following is the appropriate action for the nurse to take? • A nurse is teaching a client who has cardiovascular disease how to reduce his intake of sodium and cholesterol. The nurse understands that the most significant factor in planning dietary changes for this client is the • A nurse is caring for an older adult client who is confused and continually grabs at the nurses. Which of the following is an nursing action? • An assistive personnel (AP) tells the nurse, "I am unable to find a large blood pressure cuff for a client who is obese. Can I just use the regular cuff if I can get it to stay on?" The nurse replies that taking the blood pressure of a morbidly obese client with a regular blood pressure cuff will result in a reading that is • Which of the following should the nurse do first when preparing to provide tracheostomy care? • A 3 year old child has had multiple tooth extractions while under general anesthesia. The client returns from the postanesthesia care crying, but awake, from the recovery room. Which approach is likely to be successful? • A nurse admits a client to a same-day surgery center for an exploratory laparotomy procedure this morning. The client’s surgeon asks the nurse to witness the signing of the preoperative consent form. In signing the form as a witness, the nurse affirms that • To use proper body mechanics while making an occupied bed for a client on bed rest, the nurse should • Which of the following should a group of community health nurses plan as part of a primary prevention program for occupational pulmonary diseases? • When initiating cardiopulmonary resuscitation (CPR), the nurse must confirm which of the following assessment findings prior to beginning chest compressions? • A nurse on a rehabilitation unit is transferring a client from a bed to a chair. To avoid a back injury, which of the following techniques should the nurse use? . • An older adult client appears agitated when the nurse requests that the client’s dentures be removed prior to surgery and states, "I never go anywhere without my teeth." Which of the following is an appropriate nursing response? • To use the nursing process correctly, the nurse must first • A postoperative client has been diagnosed with paralytic ileus. When performing auscultation of the client's abdomen, the nurse expects the bowel sounds to be • While starting an intravenous infusion (IV) for a client, the nurse notices that her gloved hands get spotted with blood. The client has not been diagnosed with any infection transmitted via the bloodstream. Which of the following should the nurse do as soon as the task is completed? • A nurse is precepting a newly licensed nurse who is preparing to help a client perform tracheostomy care. The nurse should intervene if the equipment the preceptee gathered included • A nurse is caring for a client diagnosed with a terminal illness. The client asks several questions about the nurse’s religious beliefs related to death and dying. An appropriate nursing response is to • When assessing a client’s heart sounds, the nurse hears a scratching sound during both systole and diastole. These sounds become more distinct when the nurse has the client sit up and lean forward. The nurse should document the presence of a(n) • A client admitted with abdominal pain tells the nurse that her father died recently, and she begins crying while talking about him. The nurse determines that the client’s temperature is 39.2° C (102.6° F), her abdomen is soft without tenderness, and her menses is overdue by 2 days. To which observation should the nurse give priority attention? • At the surgical scrub sink, a surgical nurse demonstrates the proper surgical handwashing technique by scrubbing • A client scheduled for a hysterectomy has not yet signed the operative consent form. When the nurse approaches the client and asks that she review and sign the form, the client says she no longer wants to have the surgery. At this time, which action should the nurse take? • A nurse prepares to admit a client who is immediately postoperative to the unit following abdominal surgery. When transferring the client from the gurney to the bed, the nurse should • A client is admitted to the hospital in the terminal stage of cancer. The nurse enters the client’s room to administer medications and finds the client crying. The appropriate nursing action is to • A nurse is performing an abdominal assessment of an adult client. Identify the correct sequence of steps used for this assessment. • While measuring a client's vital signs, the nurse notices an irregularity in the heart rate. Which nursing action is appropriate? • A nurse is caring for a client who has hypertension. Which approach is the priority when the nurse is measuring the client's blood pressure? • A hospitalized client needs a chest x ray. The radiology department calls the nursing unit and says that they are sending a transporter for the client. When entering the client’s room, the priority action is to • An older adult client just diagnosed with colon cancer asks the nurse what the primary care provider is going to do. The provider will be making rounds within the hour. Which of the following nursing actions is appropriate? • A nurse is teaching a client with a new colostomy about how to irrigate the ostomy. The nurse realizes that the client needs further teaching when the client • When replacing a client's surgical dressing, the nurse should • When a nurse makes an initial assessment of a client who is postoperative following a gastric resection, the client’s nasogastric tube is not draining. The nurse's attempt to irrigate the tube with 10 mL of 0.9% sodium chloride is unsuccessful, so she determines that the tube is obstructed. Which of the following actions should the nurse take? • A client returning from the surgical suite following a vaginal hysterectomy is awake and asking for something to drink. her postoperative diet prescription reads: Clear liquids; advance diet as tolerated. Which of the following is appropriate for the nurse to tell the client? • The mother of a toddler calls to the nurse, "Help! My baby is choking on his food." The nurse determines that the Heimlich maneuver is necessary based on which finding? • A nurse is caring for a client who is 3 days postoperative following a cholecystectomy. The nurse suspects a wound infection because the drainage on the dressing is yellow and thick. The nurse identifies this type of drainage as • A nurse is caring for a client who has a new prescription for tube feeding. The nurse understands that the provider prescribed tube feeding because the client • A nurse takes an older adult client who has dysphagia following a cerebrovascular accident (CVA) to the dining room for dinner. When assisting the client at mealtime, the nurse should • A nurse is collecting a urine specimen for a client to test via urine dipstick the urine's specific gravity. The nurse knows the result will indicate the amount of • While changing the linen on a client’s bed, the nurse should • Which nursing action prevents injury to a client's eye during the administration of eye drops? • client returns from surgery with two Penrose drains in place. Anticipating frequent dressing changes, what should the nurse use around the incision area? • A nurse is performing an eye irrigation for a client who has been exposed to smoke and ash. Which of the following nursing actions should receive the highest priority during the irrigation? • A client develops a fecal impaction. Before digital removal of the mass, which type of enema should the nurse give to loosen the feces? • When communicating with a client who is hearing impaired the nurse should • Cardiopulmonary resuscitation (CPR) has been initiated for a client in the emergency room. The nurse understands that a critical concept related to effective cardiac (chest) compressions is the need to • A client is admitted for evaluation and control of hypertension. Several hours after the client’s admission, the nurse discovers the client supine on the floor, unresponsive to verbal or painful stimuli. The nurse’s first action at this time should be to • When ambulating a frail, older adult client, the nurse should • A nurse is caring for a client who is incontinent of loose stool and is reporting a painful perineum. Which of the following is the priority nursing action? • A client being discharged following abdominal surgery will be performing his own dressing changes at home. It is most important for the nurse to include which of the following in the discharge plan? • When obtaining a urine specimen for a culture and sensitivity from an indwelling catheter, the nurse should • A nurse is caring for a client who is receiving an intravenous infusion (IV) that has infiltrated. Which of the following would be an unexpected finding when the nurse assesses the client's infusion line and insertion site? • A client's provider has ordered that a sputum specimen be collected for culture and sensitivity. The nurse plans to collect this specimen • A postoperative client has an indwelling urinary catheter in place to gravity drainage. The nurse notes that the client’s urinary drainage bag has been empty for 2 hr. The first action the nurse should take is to • A client is hospitalized for an infection of a surgical wound following abdominal surgery. To promote healing and fight wound infection the nurse plans to arrange to increase the client's intake of • An older adult client has been hospitalized on bed rest for 1 week. The client reports elbow pain. Which of the following is an appropriate initial action for the nurse caring for this client to take? • A nurse is caring for a client who has just had a mastectomy and has a closed wound suction device (Hemovac) in place. Which nursing action will ensure proper operation of the device? • A client is recovering from gallbladder surgery performed under general anesthesia. The nurse should encourage the client to use the incentive spirometer how many times per hour? • A nurse is in a public building when someone cries out, "Help! I think he’s having a heart attack!" The nurse responds to the scene and finds an unconscious adult lying on the floor. Another bystander has obtained an automated external defibrillator (AED). The nurse’s first action, after making certain someone has called for emergency medical services (EMS), should be to • A nurse is caring for several clients who are receiving oxygen therapy. Which client should the nurse assess most frequently for manifestations of oxygen toxicity? The client receiving • A nurse is caring for a client who is postoperative following a partial colectomy. The client has a nasogastric tube set to low continuous suction. The client tells the nurse that his throat is sore and asks the nurse when the nasogastric tube will be taken out. Which of the following responses by the nurse is appropriate at this time? • In planning care for a client with a surgical wound healing by secondary intention, the nurse can anticipate that the client will • A client recovering from an appendectomy for a ruptured appendix has a surgical wound healing by secondary intention. When changing the client’s dressing, which observation should the nurse report to the client’s surgeon? • The nurse is caring for an adult client who has fluid volume excess. When weighing this client, the nurse should • A nurse is preparing to insert a nasogastric tube for a client admitted with a bowel obstruction. Which of the following should the nurse do first? • A nurse is planning to collect a liquid stool specimen from a client for ova and parasites. Inaccurate test results may result if the nurse • A nurse has inserted an indwelling urinary catheter for a male client. Where should the nurse tape the catheter to prevent pressure on the client's urethra at the penoscrotal junction? • A nurse is assisting a client with a meal. The client suddenly grabs at her neck with both hands and appears frightened. The appropriate nursing action is to • A client who is postoperative following a laparotomy is reporting pain and a dry mouth. The client has morphine sulfate ordered to control the pain. Before administering the morphine sulfate prescribed for the client the nurse should first • A nurse is assessing a client admitted with a sudden onset of severe back pain of unknown origin. Which statement would be most effective for the nurse use to elicit further information from this client about his pain? • A nurse is assessing a client who is postoperative following thoracic surgery. Which of the following manifestations should alert the nurse to the possibility of early hypovolemic shock? • Which nursing action demonstrates safe principles of administering a routine immunization to an infant? • A nurse is caring for a female client who has an indwelling urinary catheter. The nurse determines that the assistive personnel (AP) performing hygiene care for the client requires further education about the care of indwelling catheters when she observes the AP • A nurse caring for a client who is immobilized knows that, without interventions to prevent constipation and fecal impaction, this client is at risk for • A nurse has organized a discussion session for assistive personnel (AP) at an extended care facility about cultural and religious traditions and rituals at the time of death. The nurse determines that one of the participants has a misconception when the AP states that • A nurse is caring for a client on strict bed rest. When entering the client’s room, the nurse notices flames in the waste basket. The nurse’s priority action is to • While preparing a client for discharge, the nurse teaches the proper position for postural drainage. The nurse knows that to achieve success in this teaching program, the information about the client that is most important is the • A right handed client is admitted with a fractured right arm and contusions of the left wrist following a motor vehicle crash. Which intervention should the nurse use when assisting the client with feeding? • When transcribing the orders for a client admitted with an exacerbation of systemic lupus erythematosus (SLE), a newly licensed nurse notes that the provider has prescribed a medication with which the nurse is unfamiliar. The nurse should • A client is 2 days postoperative following an appendectomy. While changing the linens on the client’s bed, the nurse notes drainage from an infected wound has soiled the bed sheet. The appropriate nursing action is to • Following an accidental fall while playing volleyball, a client is sent home in a lower leg cast due to a hairline fracture of the tibia and must use crutches. When teaching the client the four-point gait, the nurse explains that the client should • A client is prescribed a hypothermia blanket. When caring for the client, the nurse • A client is ambulating in the hallway in bare feet. What is the priority nursing action at this time? • A client is about to have a nasogastric tube (NG) inserted. The nurse explains the procedure and is ready to begin the insertion when the client says, "No way! You are not putting that hose down my throat. Get away from me." Which of the following statements is an appropriate nursing response? • A nurse is teaching a client recovering from a cerebrovascular accident how to dress. The client has residual hemiplegia, so the nurse instructs the client to do which of the following when putting on a shirt? • While eating, a client suddenly coughs a few times then attempts to cough and makes a whistling sound on inhalation. The nurse recognizes that the client is choking. When performing the Heimlich maneuver on a conscious client, which nursing action is effective? • A provider has prescribed restraints for a client who is agitated. When applying restraints, the nurse would put the client at risk by • A client who has type 1 diabetes is scheduled for an appendectomy. The client has been NPO since midnight. There are no preoperative orders for a daily insulin dose. Which intervention is appropriate? • A client admitted to a long term care facility requires total care. In providing mouth care to the client, the appropriate nursing action is to • A client is transferred to the postanesthesia care unit after a colon resection for adenocarcinoma. Which manifestation would the nurse expect to see if the client were to develop internal abdominal bleeding postoperatively? • A client is being discharged to home with oxygen therapy via a nasal cannula. Which instruction should the nurse give to the client and family? • The provider orders a cleansing enema for a client having bowel surgery. Which nursing intervention is appropriate during this procedure? • A nurse is to planning to insert a nasogastric (NG) tube. The nurse understands that an improper use of the NG tube would be for • A client who reports shortness of breath requests the nurse’s help in changing positions. In addition to repositioning the client, the nurse's highest priority should be to • A client was admitted to the coronary care unit with a diagnosis of myocardial infarction (MI). After the client’s condition is stabilized, the client says to the nurse, "All this equipment is making me nervous. Am I so sick that I need all of this?" Which of the following is an appropriate nursing response? • A client taking several medications to treat congestive heart failure and rheumatoid arthritis arrives at the clinic reporting fatigue, anorexia, and nausea. Which assessment question is the nurse’s priority? • A client began having sleeping problems 6 months ago soon after being diagnosed with cancer. Prior to that, the client had good physical health, however, the client’s spouse of 50 yr died 1 yr ago this week. The client tells the nurse, "I’d be better off dead because I am totally worthless." Which of the following is an appropriate nursing response? • A nurse is planning range-of-motion exercises for a client. The nurse understands that active range of motion is performed before passive range of motion (PROM) because • A nurse is caring for a client admitted to the hospital with a high fever, chills, and dehydration. The nurse knows that which laboratory test will not help the provider confirm infection? • A nurse has just finished teaching a client with diverticulosis about appropriate dietary choices. Which selection by a client on the following day’s menu indicates to the nurse that the client understands the teaching? • Hot coffee spills and scalds a client's arm. The nurse's priority action is to • A postoperative client’s knee dressing becomes completely saturated with blood 1 hr after transfer to the clinical unit. Which of the following is an appropriate nursing action? • A nurse is preparing a client with a compression injury of the right leg for surgery. After administering the preoperative benzodiazepine, lorazepam (Ativan) as prescribed, the nurse determines that the medication was effective when the client states, • A client is transported to a post-anesthesia care unit (PACU) following a splenectomy. The abdominal dressing is dry and intact and IV fluids are infusing at 125 mL/hr. Which of the following is a priority nursing goal at this time? • A client is admitted to the hospital with generalized weakness. At dinner time, the nurse should • A nurse enters a client's room and finds the client is in respiratory arrest. What is the first action the nurse should take? • A nursing is caring for a client who is 1 day postoperative following abdominal surgery. What is the first action the nurse should take after discovering that a client’s wound has eviscerated? • During the termination phase of a therapeutic nurse client relationship, the nurse should initiate discussion about the concept of • Following an emergency splenectomy, a 17-year-old client is admitted to the nursing unit from the postanesthesia care unit (PACU). The client reports severe abdominal pain, and the client’s parents are asking to see their child. The nurse’s first action should be to • Before giving preoperative medication to a client being prepared for surgery, the nurse must make sure that the • A nurse is planning care for a client with a nasogastric tube following abdominal surgery. Which of the following should the nurse include in the plan of care? (Select all that apply.) • A nurse is caring for a 16-year-old client who has multiple injuries including a brain contusion as a result of a motor-vehicle crash. He has been combative and impulsive and has pushed the nurse away and climbed over the side rails. His parents tell the nurse, "This is not like our son at all." Which nursing intervention will best ensure the safety of this client? • A nurse caring for a preoperative client administers atropine as prescribed to • A nurse is caring for a client who is 2 days postoperative following abdominal surgery. The nurse should be concerned about which of the following findings? • Two days postoperative following a small bowel resection, a client reports gas pains in the periumbilical area. The nurse notes abdominal distentionand revises the client's care plan based on the knowledge that postoperative gas pains develop as a result of • A nurse is caring for a client who has acute renal failure. The nurse knows that on a day-to-day basis, the most accurate measure of the client’s fluid status is the • A nurse is caring for a 5 year old child returning from the surgical suite following an exploratory laparotomy and removal of a ruptured appendix. When writing the child’s nursing care plan, the nurse lists the priority intervention as • A client had a hiatal hernia repair 3 days ago. During this morning’s assessment, the client tells the nurse, "My abdomen feels swollen, I’m nauseated, and I have even more abdominal discomfort." What should be the nurse’s initial action? • A client is admitted to the hospital after being on bed rest at home. The client has been incontinent and smells strongly of urine. His spouse, who has been caring for him at home, states that she is sorry and embarrassed about the unpleasant smell. Which response by the nurse is therapeutic? • Within the context of the nurse client relationship, congruence on the part of the nurse implies • Central lines are used for patients who need [Show More]

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